Impact of Study Design on the Evaluation of Inhaled and Intranasal Corticosteroids’ Effect on Hypothalamic–Pituitary–Adrenal Axis Function, Part I: General Overview of HPA Axis Study Design
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Inhaled and intranasal corticosteroids (ICS and INS) are among the mainstays of the treatment for asthma and allergic
rhinitis, respectively, and also carry the potential to suppress the hypothalamic–pituitary–adrenal (HPA) axis. Several important factors
affect the interpretability of trials investigating the impact of ICS and INS on the HPA axis. This paper reviews 106 published clinical
trials, peer-reviewed articles, and New Drug Application reviews of approved ICS and INS, using MEDLINE and Drugs@FDA database.
The trials included in this review evaluated the potential impact on HPA axis function of eight approved single-ingredient ICS and INS
(beclomethasone dipropionate, budesonide, ciclesonide, flunisolide, fluticasone furoate, flucticasone propionate, mometasone furoate,
and triamcinolone acetonide) and combination products containing these ingredients. The most commonly utilized design was blinded,
placebo controlled, and short term (<6 weeks) for adult trials and blinded, placebo controlled, and long term (≥6 weeks) for pediatric
trials. Factors potentially affecting trial results include the choice of dose, dosing duration, assay sensitivity, statistical methodology, and the
study population evaluated (patients or healthy volunteers). All of these factors have the potential to affect the level of adrenal suppression
detected. In conclusion, to be informative, a HPA axis study should be well designed and carefully implemented to minimize variability in
results and improve the overall interpretability of data obtained.